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FORMAT ASUHAN KEPERAWATAN

Tgl / Jam MRS : ...............................................................................................


Tgl / Jam Pengkajian :................................................................................................
Metode Pengkajian :................................................................................................
Diagnosis Medis :................................................................................................
No. Registrasi :................................................................................................

A. PENGKAJIAN
1. Pengumpulan Data
a. Identitas Klien
1) Nama : ......................................................................................
2) Jenis Kelamin : ......................................................................................
3) Umur : ......................................................................................
4) Status Perkawinan : ......................................................................................
5) Pekerjaan : ......................................................................................
6) Agama : ......................................................................................
7) Pendidikan Terakhir : ......................................................................................
8) Alamat : ......................................................................................

b. Identitas Penanggung Jawab


1) Nama : ................................................................
2) Jenis Kelamin : ................................................................
3) Umur : ................................................................
4) Pekerjaan : ................................................................
5) Pendidikan : ................................................................
6) Alamat : ................................................................
7) Hubungan dengan Klien : ................................................................

c. Keluhan Utama (Saat Pengkajian)

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d. Riwayat Penyakit Sekarang

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e. Riwayat Kesehatan / Penyakit Yang Lalu

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f. Riwayat Kesehatan Keluarga

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g. Pola Aktifitas Sehari—hari
1) Makan dan Minum
Sebelum MRS : ....................................................................................................
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Ketika MRS : .......................................................................................................
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2) Pola Eliminasi
a. BAB

Sebelum MRS : ....................................................................................................


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Ketika MRS : ........................................................................................................
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b. BAK
Sebelum MRS : ....................................................................................................
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Ketika MRS : ........................................................................................................
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Analisis Keseimbangan Cairan Selama Perawatan
Intake Output Analisis

a. Minuman : ............... cc a. Urine : ................ cc


Intake : ............... cc
b. Makanan : ................ cc b. Feses : ................ cc
Output : ............. cc
c. Infus : ................. cc c. IWL : ................. cc

Total : Total : Balance :

3) Pola Istirahat dan Tidur


Sebelum MRS : ....................................................................................................
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Ketika MRS : .......................................................................................................
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4) Kebersihan Diri
Sebelum MRS : ....................................................................................................
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Ketika MRS : ........................................................................................................
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h. Pola Konsep Diri


1) Harga Diri : ..................................................................................................
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2) Ideal Diri : ....................................................................................................
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3) Identitas Diri : ...............................................................................................
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4) Gambaran Diri : ............................................................................................
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5) Peran : ............................................................................................................
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i. Pemeriksaan Fisik
1) Keadaan Umum :
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2) Tanda Vital :
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3) Pemeriksaan kepala dan leher :


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4) Pemeriksaan integumen
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5) Dada dan thorax
a. Paru – Paru
Inspeksi : ....................................................................................................

Palpasi : ......................................................................................................

Perkusi : ......................................................................................................

Auskultasi : .................................................................................................

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b. Jantung
Inspeksi : .....................................................................................................

Palpasi : ......................................................................................................

Perkusi : ......................................................................................................

Auskultasi : ..................................................................................................

6) Payudara
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7) Abdomen
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8) Genetalia
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9) Ekstrimitas
a. Atas
Kekuatan Otot : ..........................................................................................

ROM : .........................................................................................................

Pergerakan Sendi : ......................................................................................

Perubahan Bentuk Tulang : ........................................................................

Akral : .........................................................................................................

Pitting Edema : ...........................................................................................

Terpasang infus : .........................................................................................

b. Bawah
Kekuatan Otot : ...........................................................................................

ROM : .........................................................................................................

Varises : .......................................................................................................

Perubahan Bentuk Tulang : .........................................................................

Akral : .........................................................................................................

Pitting Edema : ............................................................................................

j. Pemeriksaan Neurologis
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k. Pemeriksaan Penujang
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l. Terapi/Pengobatan/Penatalaksanaan
Cairan IV : .........................................................................................................

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Obat Peroral : .....................................................................................................

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Obat Parenteral : ................................................................................................

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Obat Topikal : .....................................................................................................

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Surakarta, ..............................
Mahasiswa

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